Infection/Inflammation

Recurrent Uncomplicated Urinary Tract Infections in Women:

AUA/CUA/SUFU Guideline
Jennifer Anger, Una Lee, A. Lenore Ackerman, Roger Chou, Bilal Chughtai, J. Quentin Clemens,
Duane Hickling, Anil Kapoor, Kimberly S. Kenton, Melissa R. Kaufman, Mary Ann Rondanina,
Ann Stapleton, Lynn Stothers and Toby C. Chai
From the American Urological Association Education and Research, Inc., Linthicum, Maryland

Abbreviations
and Acronyms
AMR [ antimicrobial resistance
ASB [ asymptomatic bacteriuria
AUA [ American Urological
Association
CUA [ Canadian Urological
Association
IDSA [ Infectious Diseases So-
ciety of America
PAC [ proanthocyanidins
rUTI [ recurrent urinary tract
infection
SUFU [ Society of Urodynamics,
Female Pelvic Medicine & Uro-
genital Reconstruction
TMP [ trimethoprim
TMP-SMX [ trimethoprim-
sulfamethoxazole
UTI [ urinary tract infection
Accepted for publication April 17, 2019.
The complete unabridged version of the
guideline is available at https://www.jurology.com.
This document is being printed as submitted
independent of editorial or peer review by the
editors of The Journal of UrologyÒ.
Purpose: This document seeks to establish guidance for the evaluation and
management of women with recurrent urinary tract infections (rUTI) to prevent
inappropriate use of antibiotics, decrease the risk of antibiotic resistance, reduce
adverse effects of antibiotic use, provide guidance on antibiotic and non-
antibiotic strategies for prevention, and improve clinical outcomes and quality
of life by reducing recurrence of urinary tract infection (UTI) events.
Materials and Methods: The systematic review utilized to inform this guideline
was conducted by a methodology team at the Pacific Northwest Evidence-based
Practice Center. A research librarian conducted searches in Ovid MEDLINE
(1946 to January Week 1 2018), Cochrane Central Register of Controlled Trials
(through December 2017) and Embase (through January 16, 2018). An update
literature search was conducted on September 20, 2018.
Results: When sufficient evidence existed, the body of evidence was assigned a
strength rating of A (high), B (moderate), or C (low). Such evidence-based
statements are provided as Strong, Moderate, or Conditional Recommenda-
tions. In instances of insufficient evidence, additional guidance is provided as
Clinical Principles and Expert Opinions.
Conclusions: Our ability to diagnose, treat, and manage rUTI long-term has
evolved due to additional insights into the pathophysiology of rUTI, a new
appreciation for the adverse effects of repetitive antimicrobial therapy, rising
rates of bacterial antimicrobial resistance (AMR), and better reporting of the
natural history and clinical outcomes of acute cystitis and rUTI. As new data
continue to emerge in this space, this document will undergo review to ensure
continued accuracy.
Key Words: urinary bladder, urinary tract infections, women, recurrence

INTRODUCTION bacterial cystitis in their lifetime,

rUTI is a highly prevalent, costly, and
burdensome condition affecting women
of all ages, races, and ethnicities
without regard for socioeconomic
status, or educational level.1 The
incidence and prevalence of rUTI
depend on the definition used.
Approximately 60% of women will
experience symptomatic acute
which is frequently denoted as a
UTI.2 An estimated 20-40% of
women who have had one previous
cystitis episode are likely to experi-
ence an additional episode, 25-50% of
whom will experience multiple recur-
rent episodes.3,4 The evaluation and
treatment of UTI costs several billion
dollars globally per year, reaching

0022-5347/19/2022-0282/0 https://doi.org/10.1097/JU.0000000000000296
THE JOURNAL OF UROLOGY® Vol. 202, 282-289, August 2019
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282 j www.auajournals.org/jurology
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 RECURRENT UNCOMPLICATED URINARY TRACT INFECTIONS IN WOMEN
approximately $2 billion per year in the United
States.5
Terminology and Definitions
In this guideline, the term UTI will refer to culture-
proven acute bacterial cystitis and associated symp-
toms unless otherwise specified. Based on strong
evidence, the diagnosis of acute cystitis should
include the combination of laboratory confirmation of
significant bacteriuria with endorsement of acute-
onset symptoms referable to the urinary tract.6,7
Without symptoms, bacteriuria of any magnitude is
considered asymptomatic bacteriuria (ASB). The
definitions used in this guideline can be found in
table 1 of the supplementary unabridged guideline
(https://www.jurology.com).
Index Patient
The Index Patient for this guideline is an otherwise
healthy adult female with uncomplicated rUTIs.
This guideline does not apply to pregnant women,
patients who are immunocompromised, those with
anatomic or functional abnormalities of the urinary
tract, women with rUTIs due to self-catheterization
or indwelling catheters, or those exhibiting signs or
symptoms of systemic bacteremia (e.g., fever, flank
pain).3 This guideline also excludes those with
neurological disease or illness relevant to the lower
urinary tract, including peripheral neuropathy,
diabetes, and spinal cord injury. Further, this
guideline does not discuss prevention of UTI in
operative or procedural settings.
Symptoms
When evaluating UTI, acute-onset symptoms
attributable to the urinary tract typically include
dysuria in conjunction with variable degrees of
increased urinary urgency and frequency, hematu-
ria, and new or worsening incontinence. Dysuria is
central in the diagnosis of UTI; other symptoms
may be variably present. Acute-onset dysuria is a
highly specific symptom, with more than 90% ac-
curacy for UTI in young women in the absence of
concomitant vaginal irritation or increased vaginal
discharge.8,9 In older adults, the symptoms of UTI
may be less clear. Given the subjective nature of
these symptoms, careful evaluation of their chro-
nicity becomes an important consideration when the
diagnosis of UTI is in doubt.
Antimicrobial Stewardship
In the past 20 years, AMR among uropathogens has
increased dramatically. Adhering to a program of
antimicrobial stewardship with attempts to reduce
inappropriate treatment, decrease broad-spectrum
antibiotic use, and appropriately tailor necessary
treatment to the shortest effective duration, will
significantly mitigate increasing fluoroquinolone and
Copyright © 2019 American Urological Association Education and Research, Inc. Unauthorized reproduction of this article is prohibited.
283
cephalosporin resistance.10 Also, as AMR patterns
vary regionally, the specific treatment recommenda-
tions for acute cystitis episodes and rUTI prophylaxis
may not be appropriate in every community. Pro-
viders should combine knowledge of the local anti-
biogram with selection of antimicrobial agents with
the least impact on normal vaginal and fecal flora.
Patient Education
Substantial effort should be made to avoid unnec-
essary treatment unless there is a high suspicion of
UTI. Antibiotic treatment of suspected UTI remains
common practice, but expectant management with
analgesics is likely underutilized. Indeed, evidence
suggests that supportive care can be reasonably
attempted while awaiting urine cultures.
The Panel supports discussion with patients
regarding certain modifiable behaviors, including
changing mode of contraception and increasing
water intake. Unfortunately, there are many
commonly held myths surrounding lifestyle modifi-
cation. Case-control studies clearly demonstrate
that changes in hygiene practices (front to back
wiping), pre- and post-coital voiding, avoidance of
hot tubs, tampon use, and douching, do not play a
role in rUTI prevention.11,12
METHODOLOGY
A research librarian conducted searches in Ovid MED-
LINE (1946 to January Week 1 2018), Cochrane Central
Register of Controlled Trials (through December 2017)
and Embase (through January 16, 2018). Searches of
electronic databases were supplemented by reviewing
reference lists of relevant articles. An update search was
conducted for additional publications on September 20,
2018. Database searches resulted in 6,153 potentially
relevant articles. After dual review of abstracts and titles,
214 systematic reviews and individual studies were
selected for full-text dual review, and 65 studies in 67
publications were determined to meet inclusion criteria
and were included in this review. An additional 10 pub-
lications were identified in the updated literature search
and added to the review.
A full description of the AUA methodology system and
an overview of the AUA nomenclature system (table 2)
can be found in the supplementary unabridged guideline
(https://www.jurology.com).
GUIDELINE STATEMENTS
The statements provided herein should be used in
conjunction with the associated algorithm (see
figure).
Evaluation
1. Clinicians should obtain a complete patient history
and perform a pelvic examination in women presenting
with rUTIs. (Clinical Principle)
 284 RECURRENT UNCOMPLICATED URINARY TRACT INFECTIONS IN WOMEN
2. To make a diagnosis of rUTI, clinicians must docu-
ment positive urine cultures associated with prior symp-
tomatic episodes. (Clinical Principle)
3. Clinicians should obtain repeat urine studies when an
initial urine specimen is suspect for contamination, with
consideration for obtaining a catheterized specimen.
(Clinical Principle)
4. Cystoscopy and upper tract imaging should not be
routinely obtained in the index patient presenting with
rUTI. (Expert Opinion)
Patients with rUTIs should have a complete his-
tory obtained, including an assessment of lower uri-
nary tract symptoms such as dysuria, frequency,
urgency, nocturia, incontinence, hematuria, pneuma-
turia, and fecaluria. Baseline genitourinary symp-
toms between infections may also be illuminative. UTI
history includes frequency of UTI, antimicrobial
usage, and documentation of positive cultures and
the type of cultured microorganisms. Risk factors
for complicated UTI should also be elucidated.
Copyright © 2019 American Urological Association Education and Research, Inc. Unauthorized reproduction of this article is prohibited.
Additionally, a physical examination including an
abdominal exam and a detailed pelvic examination
should be performed to look for any structural or
functional abnormalities, specifically vaginal atrophy
and pelvic organ prolapse.
5. Clinicians should obtain urinalysis, urine culture
and sensitivity with each symptomatic acute cystitis
episode prior to initiating treatment in patients with
rUTIs. (Moderate Recommendation; Evidence Level:
Grade C)
6. Clinicians may offer patient-initiated treatment (self-start
treatment) to select rUTI patients with acute episodes
while awaiting urine cultures. (Moderate Recommenda-
tion; Evidence Level: Grade C)
Microbial confirmation at the time of acute-onset
urinary tract-associated symptoms and signs is an
important element in establishing a diagnosis of
rUTI. Continued documentation of cultures during
 RECURRENT UNCOMPLICATED URINARY TRACT INFECTIONS IN WOMEN
symptomatic periods (obtained prior to instituting
antimicrobial therapy) helps to provide a baseline
against which interventions can be evaluated, al-
lows for determination of the appropriate pathway
within the treatment algorithm, and provides
tailoring of therapy based on bacterial antimicrobial
sensitivities. A lack of correlation between microbi-
ological data and symptomatic episodes should
prompt a diligent consideration of alternative or
comorbid diagnoses.
Although no studies were identified specifically
designed to document direct effects of procuring
urinalysis and urine culture with antibiotic sen-
sitivities prior to initiating treatment, the Panel
determined each episode should be clinically
evaluated as a unique event. Urinalysis can
determine the presence of epithelial cells sug-
gesting contamination. 13 Such information from
a urinalysis may indicate obtaining a cathe-
terized specimen is reasonable to accurately
evaluate the patient’s culture results; however,
urinalysis provides little increase in diagnostic
accuracy.14,15
The Panel does not advocate use of either point
of care dipstick or home dipstick analysis to di-
agnose rUTI and guide treatment decisions due to
the poor sensitivity and specificity of these mo-
dalities. The Panel does recognize that in select
patients with rUTIs with symptoms of recurrence,
presumptive treatment with antibiotics can be
initiated prior to finalization of the culture results
based on prior speciation, susceptibilities, and
local antibiogram. Although the original concept
behind self-start therapy allowed for women to
treat their UTIs without the need for a culture,
the Panel recommends obtaining culture data for
symptomatic recurrences when feasible to reduce
overuse of antibiotics and the development of
antibiotic resistance.
Asymptomatic Bacteriuria
7. Clinicians should omit surveillance urine testing,
including urine culture, in asymptomatic patients with
rUTIs. (Moderate Recommendation; Evidence Level:
Grade C)
8. Clinicians should not treat ASB in patients. (Strong
Recommendation; Evidence Level: Grade B)
Without symptoms, bacteriuria of any magni-
tude is considered “ASB.” While pregnant women
and patients scheduled to undergo invasive urinary
tract procedures do benefit from treatment, sub-
stantial evidence supports that other populations,
including women with diabetes mellitus and long-
term care facility residents, do not require or
benefit from additional evaluation or antimicrobial
treatment. Evaluation and treatment of rUTIs
Copyright © 2019 American Urological Association Education and Research, Inc. Unauthorized reproduction of this article is prohibited.
285
should be performed only when acute cystitis
symptoms are present.
Antibiotic Treatment
9. Clinicians should use first-line therapy (i.e., nitrofur-
antoin, trimethoprim-sulfamethoxazole [TMP-SMX],
fosfomycin) dependent on the local antibiogram for
the treatment of symptomatic UTIs in women.
(Strong Recommendation; Evidence Level: Grade B)
10. Clinicians should treat rUTI patients experiencing
acute cystitis episodes with as short a duration of anti-
biotics as reasonable, generally no longer than seven
days. (Moderate Recommendation; Evidence Level:
Grade B)
11. In patients with rUTIs experiencing acute cystitis ep-
isodes associated with urine cultures resistant to oral
antibiotics, clinicians may treat with culture-directed
parenteral antibiotics for as short a course as reason-
able, generally no longer than seven days. (Expert
Opinion)
The AUA systematic review highlights a key
concept discussed in the Infectious Diseases So-
ciety of America (IDSA) 2011 guidelines for
treatment of acute uncomplicated UTI, namely,
that if antimicrobial therapies for UTI are
compared based upon efficacy in achieving clinical
and/or bacteriological cure, there is relatively lit-
tle to distinguish one agent from another. How-
ever, the IDSA guidelines introduced the concepts
of resistance prevalence and collateral damage as
key considerations in choosing UTI treatments.16
The three first-line agents available in the United
States (i.e., nitrofurantoin, TMP-SMX, fosfomy-
cin) are effective in treating UTI but are less likely
to produce collateral damage than are second-line
agents.16 Table 3 in the supplementary un-
abridged guideline (https://www.jurology.com)
shows first-line agents recommended by the IDSA
guidelines. Second-line or alternate therapies are
generally chosen because of resistance patterns
and/or allergy considerations.
There is limited high quality up-to-date evidence
of comparative trials on the length of antibiotic
therapies for complete resolution of UTI symptoms.
Generally, all antibiotics have risks, irrespective of
class, and, as such, stewardship should be exercised
to balance symptom resolution with reducing risk of
recurrence. There are two systematic reviews that
compared shorter versus longer courses of antibiotics
for UTI.17e19 Single-dose antibiotics were associated
with increased risk of short-term (<2 weeks after
treatment) bacteriological persistence versus short
course (3 to 6 days; 5 studies, RR 2.01, 95% CI
1.05e3.84, I2[36%) or long course (7-14 days; 6
studies, RR 1.93, 95% CI 1.01e3.70, I2[31%) anti-
biotic therapy.
 286 RECURRENT UNCOMPLICATED URINARY TRACT INFECTIONS IN WOMEN
Antibiotic Prophylaxis
12. Following discussion of the risks, benefits, and alter-
natives, clinicians may prescribe antibiotic prophylaxis
to decrease the risk of future UTIs in women of all
ages previously diagnosed with UTIs. (Moderate Recom-
mendation; Evidence Level: Grade B)
The results of trials on prophylactic antibiotics
consistently demonstrate the positive effect of this
preventive treatment, while acknowledging the in-
crease in mild, moderate, and severe adverse events
associated with antibiotic use. The effects of anti-
biotic prophylaxis have been shown to last during
the active intake time period, with UTI recurrence
equaling that of the placebo arm following cessation
of prophylaxis.
Adverse Events. All antibiotics have potential risks.
These risks should be discussed with patients prior
to prescribing for short-, medium-, or long-term
prophylaxis. Nitrofurantoin is commonly prescribed
in women of all ages and has potentially serious
risks of pulmonary and hepatic toxicity.20e23 The
rates of possible serious pulmonary or hepatic
adverse events are extremely low, and are reported
to be 0.001% and 0.0003%, respectively.24 Potential
adverse effects of gastrointestinal disturbances and
skin rash are commonly associated with antibiotics,
including trimethoprim (TMP), TMP-SMX,
cephalexin, and fosfomycin.25,26
Dosing and Duration. The most tested schedule
of antibiotic prophylaxis (TMP, TMP-SMX,
nitrofurantoin, cephalexin) was daily dosing.
However, fosfomycin used prophylactically is dosed
every 10 days. The duration of antibiotic prophylaxis
in the literature ranged from 6 to 12 months. In
clinical practice, the duration of prophylaxis can be
variable, from three to six months to one year, with
periodic assessment and monitoring. Some women
stay on continuous or post-coital prophylaxis for
years to maintain the benefit without adverse
events. However, it should be noted that continuing
prophylaxis for years is not evidence-based.
In women who experience UTIs temporally
related to sexual activity, antibiotic prophylaxis
taken before or after sexual intercourse has been
shown to be effective and safe. This use of antibi-
otics is associated with a significant reduction in
recurrence rates. Additionally, intermittent dosing
is associated with decreased risk of adverse events
including gastrointestinal symptoms and vaginitis.
Common dosing regimens can be found in the table.
Non-Antibiotic Prophylaxis
13. Clinicians may offer cranberry prophylaxis for rUTIs.
(Conditional Recommendation; Evidence Level: Grade C)
There has been a growing concern regarding anti-
biotic resistance in the setting of rUTI. In 2015 the
Copyright © 2019 American Urological Association Education and Research, Inc. Unauthorized reproduction of this article is prohibited.
Antibiotic prophylaxis dosing
Continuous prophylaxis:
TMP 100 mg once daily
TMP-SMX 40 mg/200 mg once daily, 40 mg/200 mg thrice
weekly
Nitrofurantoin 50 mg daily, 100 mg daily
Cephalexin 125 mg once daily, 250 mg once daily
Fosfomycin 3 gm every 10 days
Intermittent prophylaxis:
TMP-SMX 40 mg/200 mg, 80 mg/400 mg
Nitrofurantoin 50e100 mg
Cephalexin 250 mg
World Health Organization increased awareness of the
issue of the growing world-wide phenomenon of AMR
through its publication Global Action Plan on Antimi-
crobial Resistance,27 which has led to an increasing
interest in the scientific community to study non-
antibiotic modalities in the prevention of rUTI.
Cranberry. Recently cranberry has been the subject
of an increasing number of randomized clinical tri-
als. These studies have used cranberry in a variety
of formulations including juice, cocktail, and tablets.
The proposed mechanism of action is thought to be
related to proanthocyanidins (PACs) present in
cranberries and the ability of PACs to prevent the
adhesion of bacteria to the urothelium. It must be
noted that PACs are found in varying concentra-
tions dependent on the formulation used, and many
of the cranberry products used in scientific study
are explicitly formulated for research purposes. The
availability of such products to the public is a severe
limitation to the use of cranberries for rUTI pro-
phylaxis outside the research setting and must be
discussed with patients.
Cranberry, in a formulation that is available and
tolerable to the patient, may be offered as prophy-
laxis, including oral juice and tablet formulations, as
there is not sufficient evidence to support one
formulation over another when considering this food-
based supplement. In addition, there is little risk to
cranberry supplements, further increasing their ap-
peal to patients. However, it must be noted that fruit
juices can be high in sugar content, which is a
consideration that may limit use in diabetic patients.
Alternative Non-Antibiotic Prophylaxis. A number of
other options are also available for use; however, the
Panel was unable to find sufficient evidence to support
their efficacy as prophylactic agents. Such other agents
include lactobacillus, D-mannose, methenamine,
herbs/supplements, intravesical hyaluronic acid/
chondroitin, biofeedback, and immunoactive
therapy.
Follow-up Evaluation
14. Clinicians should not perform a post-treatment
test of cure urinalysis or urine culture in asymptom-
atic patients. (Expert Opinion)
 RECURRENT UNCOMPLICATED URINARY TRACT INFECTIONS IN WOMEN
15. Clinicians should repeat urine cultures to guide
further management when UTI symptoms persist
following antimicrobial therapy. (Expert Opinion)
Extrapolating from the ASB literature, the Panel
does not endorse microbiological reassessment (i.e.
repeat urine culture) after successful UTI treatment
as this may lead to overtreatment. It should again
be emphasized that symptom clearance is sufficient.
In patients with rapid recurrence (particularly with
the same organism), clinicians may consider evalu-
ation on and off therapy to help identify those pa-
tients who warrant further urologic evaluation.
Additionally, repeated infection with bacteria asso-
ciated with struvite stone formation (e.g., P. mir-
abilis) may prompt consideration of imaging to rule
out calculus.
After initiating antimicrobial therapy for UTI,
clinical cure (i.e. UTI symptom resolution) is ex-
pected within three to seven days. Although there
is no evidence, the Panel felt it reasonable to repeat
a urine culture if UTI symptoms persist beyond
seven days. Although a second antibiotic can be
given empirically, this should only be done after a
urine sample is obtained for culture. This will
minimize unnecessary treatment of patients with
persistent UTI/pain symptoms who are culture-
negative.
Estrogen
16. In peri- and post-menopausal women with rUTIs, cli-
nicians should recommend vaginal estrogen therapy to
reduce the risk of future UTIs if there is no contraindication
to estrogen therapy. (Moderate Recommendation; Evi-
dence Level: Grade B)
Clinicians should recommend vaginal estrogen
therapy to all peri- and post-menopausal women
with rUTIs to reduce the risk of future UTIs. This
is in contrast to oral or other formulations of
systemic estrogen therapy, which have not been
shown to reduce UTI risk and are associated with
different risks and benefits. Patients who present
with rUTIs and are already on systemic estrogen
therapy can and should still be placed on vaginal
estrogen therapy. There is no substantially
increased risk of adverse events. However, sys-
temic estrogen therapy should not be recom-
mended for treatment of rUTI. Table 5 in the
supplementary unabridged guideline (https://
www.jurology.com) shows the formulations and
dosing of several commonly used types of vaginal
estrogen therapy.
As part of shared decision-making, the clinician
should weigh the risks associated with vaginal es-
trogen therapy with its benefits in reducing UTI
risk. Given low systemic absorption, systemic risks
association with vaginal estrogen therapy are min-
imal. Vaginal estrogen therapy has not been shown
Copyright © 2019 American Urological Association Education and Research, Inc. Unauthorized reproduction of this article is prohibited.
287
to increase risk of cancer recurrence in women un-
dergoing treatment for or with a personal history of
breast cancer.28e30 Therefore, vaginal estrogen
therapy should be considered in prevention of UTI
for women with a personal history of breast cancer
in coordination with the patient’s oncologist.
FUTURE DIRECTIONS
A worldwide crisis has emerged due to rapid
expansion of multi-drug resistant bacteria, fore-
shadowing the devastating implications of the
eventual inefficacy of many of our broad-spectrum
antimicrobial agents.27 Current concepts of anti-
biotic stewardship have provoked a further initia-
tive to develop agents outside the traditional
pipeline of antibiotics. Critical to these agendas on
a more immediate time frame is the need for
comprehensive randomized controlled trials for
non-antibiotic prevention therapies. Implementation
of novel technologies, such as vaccines for urinary
pathogens, may represent a fertile future direction.
Use of mannosides as therapeutic entities to pre-
vent bacterial adhesion to the urothelium may
target a narrow-spectrum treatment strategy asso-
ciated with few systemic manifestations.31 Modu-
lation of host responses, such as the use of
non-steroidal anti-inflammatory agents, have been
suggested as a useful adjunct in both preclinical and
clinical studies.32,33
We must also expand our perspective of rUTI to
include prevention. There currently exists an NIH-
funded research consortium addressing this mission-
the Prevention of Lower Urinary Tract Symptoms
(PLUS) Research Consortium.34 This consortium is
dedicated to promoting prevention of lower urinary
tract symptoms (including UTIs) across the woman’s
life spectrum, utilizing a socioecologic construct.35
Critical to these investigative efforts is discovery of
methods to suppress symptoms without use of anti-
biotics and direct studies that support a broader view
of rUTI from the host-pathogen perspective. Through
multiple efforts, which include identifying modifiable
socioecological risk factors, understanding host re-
sponses in UTI and understanding pathogen viru-
lence factors, we will discover new methods in the
diagnosis and treatment of rUTI.
DISCLAIMER
This document was written by the Recurrent Uri-
nary Tract Infection Guideline Panel of the American
Urological Association Education and Research, Inc.,
which was created in 2017. The Practice Guidelines
Committee (PGC) of the AUA selected the committee
chair. Panel members were selected by the chair
in coordination with the Canadian Urological
 288 RECURRENT UNCOMPLICATED URINARY TRACT INFECTIONS IN WOMEN

Association (CUA) and the Society of Urodynamics,
Female Pelvic Medicine & Urogenital Reconstruction
(SUFU). Membership of the panel included special-
ists with specific expertise on this disorder. The
mission of the panel was to develop recommenda-
tions that are analysis-based or consensus-based,
depending on panel processes and available data,
for optimal clinical practices in the diagnosis and
treatment of recurrent urinary tract infection.
Funding of the panel was provided by the AUA
with contributions from CUA and SUFU. Panel
members received no remuneration for their work.
Each member of the panel provides an ongoing
conflict of interest disclosure to the AUA.
While these guidelines do not necessarily establish
the standard of care, AUA seeks to recommend and to
encourage compliance by practitioners with current
best practices related to the condition being treated. As
medical knowledge expands and technology advances,
the guidelines will change. Today these evidence-
based guidelines statements represent not absolute
mandates but provisional proposals for treatment
under the specific conditions described in each docu-
ment. For all these reasons, the guidelines do not pre-
empt physician judgment in individual cases.
Treating physicians must take into account vari-
ations in resources, and patient tolerances, needs,
and preferences. Conformance with any clinical
guideline does not guarantee a successful outcome.
The guideline text may include information or rec-
ommendations about certain drug uses (‘off label’)
that are not approved by the Food and Drug
Administration (FDA), or about medications or sub-
stances not subject to the FDA approval process.
AUA urges strict compliance with all government
regulations and protocols for prescription and use of
these substances. The physician is encouraged to
carefully follow all available prescribing information
about indications, contraindications, precautions and
warnings. These guidelines and best practice state-
ments are not intended to provide legal advice about
use and misuse of these substances.
Although guidelines are intended to encourage
best practices and potentially encompass available
technologies with sufficient data as of close of the
literature review, they are necessarily time-
limited. Guidelines cannot include evaluation of
all data on emerging technologies or management,
including those that are FDA-approved, which
may immediately come to represent accepted
clinical practices.
For this reason, the AUA does not regard tech-
nologies or management which are too new to be
addressed by this guideline as necessarily experi-
mental or investigational.
DISCLOSURES
All panel members completed COI disclosures.
Disclosures listed include both topice and non-
topic-related relationships.
Consultant/Advisor: Toby Chai, Avadel; A. Lenore
Ackerman, Aquinox Pharmaceuticals; Bilal
Chughtai, Boston Scientific; J. Quentin Clemens,
Aquinox, Medtronic; Duane Hickling, Astellas,
Pfizer, Allergan; Anil Kapoor, Pfizer, Bayer Oncology,
Novartis Oncology; Melissa Kaufman, Boston Scien-
tific; Kimberly Kenton, Boston Scientific; Ann Sta-
pleton, Paratek.
Meeting Participant or Lecturer: Bilal Chughtai,
Allergan; J. Quentin Clemens, Allergan; Duane
Hickling, Astellas, Pfizer, Allergan; Anil Kapoor,
Pfizer, Bayer Oncology, Novartis Oncology; Una
Lee, Medtronic.
Scientific Study or Trial: Jennifer Anger, Boston
Scientific, AMS; Bilal Chughtai, American Uro-
logical Association, Boston Scientific; Duane
Hickling, Astellas; Anil Kapoor, Pfizer, Novartis
Oncology; Kimberly Kenton, Boston Scientific;
Lynn Stothers, IPSEN.
Investment Interest: J. Quentin Clemens, Merck.
Health Publishing: J. Quentin Clemens, UpToDate.
Other: Jennifer Anger, Boston Scientific; Melissa
Kaufman, Boston Scientific, Cook Myosite; Mary
Ann Rondanina, Theravance Biopharma.

REFERENCES
1. Wagenlehner F, Wullt B, Ballarini S et al:
Social and economic burden of recurrent
urinary tract infections and quality of life: a
patient web-based study (GESPRIT). Expert
Rev Pharmacoecon Outcomes Res 2018; 18:
107.
2. Foxman B: Urinary tract infection syndromes:
occurrence, recurrence, bacteriology, risk factors,
and disease burden. Infect Dis Clin North Am
2014; 28: 1.
3. Geerlings SE: Clinical presentations and epide-
miology of urinary tract infections. Microbiol
Spectr 2016; 4.
4. Gupta K, Trautner BW: Diagnosis and manage-
ment of recurrent urinary tract infections in non-
pregnant women. BMJ 2013; 346: f3140.
5. Foxman B: Epidemiology of urinary tract in-
fections: incidence, morbidity, and economic
costs. Am J Med 2002; 113: 5S.
6. Dason S, Dason JT, Kapoor A: Guidelines for the
diagnosis and management of recurrent urinary
tract infection in women. Can Urol Assoc J 2011;
5: 316.
7. Finucane TE: “Urinary tract infection” erequiem for
a heavyweight. J Am Geriatr Soc 2017; 65: 1650.
8. Hooton TM: Clinical practice. Uncomplicated
urinary tract infections. N Engl J Med 2012; 366;
1028.

Copyright © 2019 American Urological Association Education and Research, Inc. Unauthorized reproduction of this article is prohibited.
 RECURRENT UNCOMPLICATED URINARY TRACT INFECTIONS IN WOMEN
9. Bent S, Nallamothu BK, Simel DL et al: Does this
woman have an acute uncomplicated urinary
tract infection? JAMA 2002; 287; 2701.
10. Linder JA, Huang ES, Steinman MA et al: Fluo-
roquinolone prescribing in the United States:
1995 to 2002. Am J Med 2005; 118: 259.
11. Scholes DM, Hooton TM, Roberts RL et al: Risk
factors for recurrent urinary tract infection in
young women. J Infec Dis 2000; 182: 1177.
12. Scholes DM, Hawn TR, Roberts PL et al: Family
history and risk of recurrent cystitis and pyelo-
nephritis in women. J Urol 2010; 184: 564.
13. Bradbury SM: Collection of urine specimens in
general practice: to clean or not to clean? J R
Coll Gen Pract 1988; 38: 363.
14. Miller JM, Binnicker MJ, Campbell S et al: A
guide to utilization of the microbiology laboratory
for diagnosis of infectious diseases: 2018 update
by the Infectious Diseases Society of America
and the American Society for Microbiology. Clin
Infect Dis 2018; 67: 813.
15. Hilt EE, McKinley K, Pearce MM et al: Urine is
not sterile: use of enhanced urine culture
techniques to detect resident bacterial flora in
the adult female bladder. J Clin Microbiol 2014;
52: 871.
16. Gupta K, Hooton TM, Naber KG et al: Interna-
tional clinical practice guidelines for the treat-
ment of acute uncomplicated cystitits and
pyelonephritis in women: a 2010 update by the
Infectious Diseases Society of America and the
European Society for Microbiology and Infectious
Diseases. Clin Infect Dis 2011; 52: e103.
17. Milo G, Katchman EA, Paul M et al: Duration of
antibacterial treatment for uncomplicated urinary
tract infection in women. Cochrane Database
Syst Rev 2005; CD004682.
Copyright © 2019 American Urological Association Education and Research, Inc. Unauthorized reproduction of this article is prohibited.
18. Katchman EA, Milo G, Paul M et al: Three-day vs
longer duration of antibiotic treatment for
cystitis in women: systematic review and meta-
analysis. Am J Med 2005; 118: 1196.
19. Lutters M, Vogt-Ferrier NB: Antibiotic duration
for treating uncomplicated, symptomatic lower
urinary tract infections in elderly women.
Cochrane Database Syst Rev 2008:Cd001535.
20. Holmberg L, Boman G, B€ottiger LE et al: Adverse
reactions to nitrofurantoin. Analysis of 921 re-
ports. Am J Med 1980; 69: 733.
21. Linnebur SA, Parnes BL: Pulmonary and hepatic
toxicity due to nitrofurantoin and fluconazole
treatment. Ann Pharmacother 2004; 38: 612.
22. Mulberg AE, Bell LM: Fatal cholestatic hepatitis and
multisystem failure associated with nitrofurantoin.
J Pediatr Gastroenterol Nutr 1993; 17: 307.
23. Sherigar JM, Fazio R, Zuang M et al: Autoim-
mune hepatitis induced by nitrofurantoin. The
importance of the autoantibodies for an early
diagnosis of immune disease. Clin Pract 2012;
2:e83.
24. D'Arcy PF: Nitrofurantoin. Drug Intell Clin Pharm
1985; 19: 540.
25. Bernstein LS: Adverse reactions to trimethoprim-
sulfamethoxazole, with particular reference to
long-term therapy. Can Med Assoc J 1975;
112: 96.
26. Iarikov D, Wassel R, Farley J et al: Adverse
events associated with fosfomycin use: review of
the literature and analysis of the FDA adverse
event reporting system database. Infect Dis Ther
2015; 4: 433.
27. World Health Organization: Antimicrobial resis-
tance. 2018. http://www.who.int/antimicrobial-
resistance/en/.
289
28. Ponzone R, Biglia N, Jacomuzzi ME et al: Vaginal
oestrogen therapy after breast cancer: is it safe?
Eur J Cancer 2005; 41: 2673.
29. Le Ray I, Dell'Aniello S, Bonnetain F et al: Local
estrogen therapy and risk of breast cancer
recurrence among hormone-treated patients: a
nested case-control study. Breast Cancer Res
Treat 2012; 135: 603.
30. O'Meara ES, Rossing MA, Dailing JR et al:
Hormone replacement therapy after a diagnosis
of breast cancer in relation to recurrence and
mortality. J Natl Cancer Inst 2001; 93: 754.
31. Spaulding CN, Klein RD, Schreiber HL IV et al:
Precision antimicrobial therapeutics: the path of
least resistance? NPJ Biofilms Microbiomes
2018; 4: 4.
32. Hannan TJ, Roberts PL, Riehl TE et al: Inhibition
of cyclooxygenase-2 prevents chronic and
recurrent cystitis. EBioMedicine 2014; 1: 46.
33. Gagyor I, Bleidorn J, Kochen MM et al: Ibuprofen
versus fosfomycin for uncomplicated urinary
tract infection in women: randomised controlled
trial. BMJ 2015; 351: h6544.
34. Harlow BL, Bavendam TG, et al: The Prevention
of Lower Urinary Tract Symptoms (PLUS)
Research Consortium: a transdiciplinary
approach toward promoting bladder health and
preventing lower urinary tract symptoms in
women across the life course. J Womens Health
2018; 27: 283.
35. Brady SS, Bavendam TG, Berry A et al: Preven-
tion of lower urinary tract symptoms (PLUS)
research consortium. The prevention of lower
urinary tract symptoms (PLUS) in girls and
women: developing a conceptual framework for
a prevention research agenda. Neurourol Urodyn
2018; 37: 2951.